Medical Miracle: Doctors Embracing Reform

April 2, 2009

Harold Pollack
is a public health policy researcher at the University of Chicago's
School of Social Service Administration, where he is faculty chair of
the Center for Health Administration Studies. He is a regular
contributor to The Treatment.

For years, the medical profession has lagged only the insurers as a designated bogeyman for many who favor health reform. If only doctors weren’t so overpaid and professionally dominant, we would have a cheaper and fairer medical system that would emphasize primary care rather than so much expensive poking, prodding, and scribbling on a prescription pad. At least so the arguments go.

Frequently enough in this drama, physicians’ visible organized presence, the American Medical Association, has willingly played a villain from central casting. My favorite example was when the AMA feared that immunization clinics would lead to socialized medicine. Medicare and other programs were pushed through Congress despite significant opposition from the very same medical providers who would later profit greatly from such legislation. Medical specialty organizations have wrongly opposed comparative effectiveness research. They fear--often quite accurately--that serious research would cast doubt on the value and cost-effectiveness of dicey medications, interventions, and procedures.

Whatever the professions’ view might have been decades ago, increasing numbers of physicians have come to favor fundamental healthcare financing and delivery reforms. On the left, Physicians for a National Health Care Program boasts 16,000 members. Although single-payer remains a minority preference among doctors, attitudes have clearly shifted. The April 2009 Journal of General Internal Medicine includes an article by Dan McCormick and colleagues that documents this shift. In a nationally representative 2007 survey, only 9 percent of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42 percent preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89 percent); 33 percent believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3 percent) believed that even the insured lack access to needed care.

Some will be quick to dismiss this survey, which was conducted by single-payer advocates, and which achieved a dicey 50.8 percent response rate. I think the study is broadly correct. Today’s physicians are much more open than their predecessors were to fundamental changes.

Most recently, Doctors for America has posted an “Open letter to Congress on the budget for healthcare reform," which reads as follows:

We, the undersigned physicians, strongly urge you to support President Obama’s proposed budget for a healthcare reform reserve fund. President Obama has presented a bold blueprint for health reform. It focuses on our most critical priorities: increased access to care that preserves patient choice reduced healthcare costs that would protect Americans from catastrophic medical bills improved quality care through better healthcare systems, information technology, and research. President Obama’s vision combines the best features of our current system with the reforms we need. These proposals and the values they represent are shared by millions of Americans. They are not Democratic or Republican values--they are American values. As physicians, we are at the frontlines of an increasingly fragmented and dysfunctional health care system. We need the tools and freedom to practice medicine as we were trained to do. Our patients need meaningful reform. So do we. The President has proposed an ambitious budget that makes a crucial down payment for health reform. We strongly urge Congress to keep the health reform reserve fund as proposed in the President’s budget. After many decades of false starts, we must make health reform a reality in 2009.

(Disclosure: I am an informal advisor to this group.)

This group is well-connected in Washington. It’s thus especially significant that they, like Jonathan Cohn, highlight the importance of the pending budget battle.

So far, more than 1,800 doctors and medical students have signed on. Many signatories might be considered usual suspects: Andy Calman of Physicians for a Democratic Majority, leading pediatricians and public health authorities. Other names, though, are less expected. A quick run-through yields Whitney Addington, President Emeritus, The American College of Physicians. There is Gregory Curfman, Executive Editor of the New England Journal of Medicine. There is Philip Pizzo, Dean of the Stanford University School of Medicine. A good number of signatories are at the pinnacle of the medical profession—the very luminaries whose predecessors were often the most dogged and effective opponents of needed reforms.

Physician opinion is rapidly changing. One could say much more, but the basic reasons are clear from 50,000 feet. Doctors witness firsthand the cruelties and idiocies imposed by our fragmented system.

Managed care organizations already impose the mindless paperwork and micromanagement physicians once feared would accompany a larger public role. Moreover, our healthcare system fails to honor basic values that physicians hold dear. Every day, general practitioners try in vein to find specialists for the Medicaid patient whose cancer diagnosis was delayed because she avoided preventive care. Oncologists watch that same patient struggle with five- and six-figure medical bills as she confronts a frightening illness. Urban providers witness overcrowded emergency rooms and a crumbling safety-net increasingly unable to provide patients with compassionate care or to provide healthcare professionals with a stable, attractive, and worthy environment to perform their work.

Sure, there will be pushing and shoving within the medical profession before this thing is done. Specialists and primary care doctors have different interests and different perspectives regarding comparative effectiveness research or the degree to which public or private payers should exercise bargaining power over provider payment. There are generational, geographic, and specialty differences within medicine regarding a myriad of concerns.

Without discounting these frictions, the medical profession is coming to see what many others have also seen. Our existing, increasingly dysfunctional healthcare system doesn’t just work poorly for patients. It works poorly for doctors and for many others, too. That’s one reason I am hopeful we will see a major reform, this year.